Does Medicare Cover Knee Replacements?
September 26, 2019
Reviewed and Updated by Troy Frink,
More than 600 thousand people need knee replacements every year, according to the American Academy of Orthopaeidic Surgeons (AAOS). If you’re one of those people and you have Medicare, you may wonder, “Does Medicare cover knee replacements?” Yes, but only in certain circumstances.
Medicare Criteria for Total Knee Replacement
In order for your Medicare plan to cover a knee replacement procedure, the surgery must be medically necessary. For example, the Centers for Medicare and Medicaid (CMS) lists the following conditions that can lead to joint replacement:
- Osteoarthritis (mild, moderate, severe)
- Inflammatory arthritis (for example, rheumatoid arthritis, psoriatic arthritis)
- Malignancy of the distal femur, proximal tibia, knee joint, and/or soft tissues
- Previous knee replacement failure
- Fractures
- Osteonecrosis (a disease caused when the joints receive less blood than normal)
*This list is not exhaustive. You may have different conditions that lead to a knee replacement.
Your doctor will perform a physical exam before recommending surgery. During the exam, your doctor will assess your range of motion, look at how you walk, and look for deformities and/or tenderness. Your doctor will likely order blood work and other lab tests to determine the best possible treatment plan.
Medicare Knee Replacement Age Limit
There is no age limit for a Medicare knee replacement. However, you may still be responsible for some out-of-pocket costs.
What Is the Cost of a Total Knee Replacement if You Are on Medicare?
The exact cost of a knee replacement surgery is hard to pinpoint. Many different factors go into the total cost of the procedure including:
- How long you spend in the operating room
- The type of anesthesia and the amount the doctor uses
- X-rays during and after the operation
- Post-surgery medications to manage pain, prevent infection, and help prevent blood clots
- How many days you spend recovering in the hospital
- Post-surgery physical therapy to help exercise your knee
According to the American Association of Hip and Knee Replacement Surgeons (AAHKS), some patients can receive outpatient total joint arthroplasty (TJA). However, most TJAs are inpatient procedures.
With Original Medicare, Part A may cover your hospital stay after you meet the Part A deductible. AAHKS says that most people stay in the hospital for 1-3 days “depending on your rehabilitation protocol and how fast you progress with physical therapy.”
If your surgeon recommends an outpatient TJA, Medicare Part B may cover the procedure. If Part B covers the procedure, you may owe 20 percent of all Medicare-approved charges, Part B may pay the remaining 80 percent.
Does Medicare Cover Knee Replacement Surgery Recovery?
Medicare Part A will cover a temporary stay in a skilled nursing facility. Original Medicare may also cover medications, testing, and other clinical services.
Medicare Part B covers postoperative follow-up appointments. Original Medicare may not cover prescription drugs to fight pain or prevent infection, but a Medicare Part D or Medicare Advantage plan with a prescription benefit can cover those medications.
Knee Replacement Cost With Medicare Advantage
If you qualify for Medicare, you can get a Medicare Advantage (MA) plan, which is a private insurance plan that can cover the same services as Original Medicare. The difference is that a MA plan can cover additional benefits such as grab bars and meal delivery for when you return home from a hospital stay.
Each MA plan may require a different deductible, copay, coinsurance payment, or out-of-pocket maximum*, so what you actually pay depends on your plan.
Some Medicare Advantage plans offer a prescription drug benefit, which Original Medicare does not. You may owe a copay or coinsurance for your postoperative medications, and those payments vary by plan.
*In 2019, the standard Medicare Out-of-Pocket Maximum (MOOP) for MA plans is $6700. Your MA plan may have a lower MOOP for Original Medicare-covered services.
Knee Replacement Cost With a Medicare Supplement Plan
While Medicare Advantage plans cover Original Medicare services plus additional benefits, Medicare Supplement (Medigap) plans cover financial items such as deductibles and coinsurance. You must choose one because you cannot have both a MA plan and a Medigap plan.
A Medicare Supplement plan can pay some or all of your out-of-pocket costs. Note: You may still owe at premium.
If you’re unsure if a Medicare Advantage or Medicare Supplement plan is right for you, a licensed agent with Medicare Plan Finder Can help. There may be many plans to choose from in your area. Our agents are highly trained and may be able to help you find a plan that suits your needs.
What’s Involved in a Knee Replacement Surgery?
Your surgery may be a total knee replacement or a partial knee replacement depending on how damaged your joint is.
Regardless if your procedure is a partial or total knee replacement, the surgery will require anesthesia. Your surgical team may use general anesthesia, which makes you sleep during the surgery, or spinal anesthesia, which makes you numb from the waste down, but you’re still awake.
During the procedure, your surgeon will bend your knee to see the entire surface of the joint. Then your surgeon will make an incision 6-10 inches long and then cut out any damaged joint surfaces.
After the joint is prepared, then your surgeon will attach the artificial joint and close the incision after making sure the new joint works properly. According to the Mayo Clinic, the procedure lasts about two hours.
Get Medicare Coverage for Knee Replacement Surgery Today
If you need a knee replacement and want to find the right Medicare plan to cover the procedure, one of our licensed agents may be able to help. There may be many plans available in your area, but how do you know which one is right for you? Your agent will assess your needs, show you the available options, and then help you determine the best path to take. To set up a no-cost, no-obligation appointment, call 844-431-1832 or contact us here today.
